Socioeconomic inequalities in the access to and quality of health care services

OBJECTIVE To assess the inequalities in access, utilization, and quality of health care services according to the socioeconomic status. METHODS This population-based cross-sectional study evaluated 2,927 individuals aged ≥ 20 years living in Pelotas, RS, Southern Brazil, in 2012. The associations between socioeconomic indicators and the following outcomes were evaluated: lack of access to health services, utilization of services, waiting period (in days) for assistance, and waiting time (in hours) in lines. We used Poisson regression for the crude and adjusted analyses. RESULTS The lack of access to health services was reported by 6.5% of the individuals who sought health care. The prevalence of use of health care services in the 30 days prior to the interview was 29.3%. Of these, 26.4% waited five days or more to receive care and 32.1% waited at least an hour in lines. Approximately 50.0% of the health care services were funded through the Unified Health System. The use of health care services was similar across socioeconomic groups. The lack of access to health care services and waiting time in lines were higher among individuals of lower economic status, even after adjusting for health care needs. The waiting period to receive care was higher among those with higher socioeconomic status. CONCLUSIONS Although no differences were observed in the use of health care services across socioeconomic groups, inequalities were evident in the access to and quality of these services.

Performance management in primary healthcare services: evidence from a field study

Health services

Orchestration of heterogeneous middleware services and its application to a comand and control platform

MSC Dissertation in Computer Engineering

Ubiquitous computing and natural interfaces for environmental information

Dissertação apresentada na Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa para obtenção do Grau de Mestre em Engenharia do Ambiente, perfil Gestão e Sistemas Ambientais

Factors associated with the nutritional status of children less than 5 years of age

OBJECTIVE To analyze if the nutritional status of children aged less than five years is related to the biological conditions of their mothers, environmental and socioeconomic factors, and access to health services and social programs.METHODS This cross-sectional population-based study analyzed 664 mothers and 790 children using canonical correlation analysis. Dependent variables were characteristics of the children (weight/age, height/age, BMI/age, hemoglobin, and retinol serum levels). Independent variables were those related to the mothers’ nutritional status (BMI, hemoglobin, and retinol serum levels), age, environmental and socioeconomic factors and access to health service and social programs. A < 0.05 significance level was adopted to select the interpreted canonical functions (CF) and ± 0.40 as canonical load value of the analyzed variables.RESULTS Three canonical functions were selected, concentrating 89.9% of the variability of the relationship among the groups. In the first canonical function, weight/age (-0.73) and height/age (-0.99) of the children were directly related to the mother’s height (-0.82), prenatal appointments (-0.43), geographical area of the residence (-0.41), and household incomeper capita (-0.42). Inverse relationship between the variables related to the children and people/room (0.44) showed that the larger the number of people/room, the poorer their nutritional status. Rural residents were found to have the worse nutritional conditions. In the second canonical function, the BMI of the mother (-0.48) was related to BMI/age and retinol of the children, indicating that as women gained weight so did their children. Underweight women tended to have children with vitamin A deficiency. In the third canonical function, hemoglobin (-0.72) and retinol serum levels (-0.40) of the children were directly related to the mother’s hemoglobin levels (-0.43).CONCLUSIONS Mothers and children were associated concerning anemia, vitamin A deficiency and anthropometric markers. Living in rural areas is a determining factor for the families health status.

Política(s) de saúde no trabalho : um inquérito sociológico às empresas portuguesas

Resumo Política(s) de saúde no trabalho: um inquérito sociológico às empresas portuguesas A literatura portuguesa sobre políticas, programas e actividades de Segurança, Higiene e Saúde no Trabalho (abreviadamente, SH&ST) é ainda escassa. Com este projecto de investigação pretende-se (i) colmatar essa lacuna, (ii) melhorar o conhecimento dos sistemas de gestão da saúde e segurança no trabalho e (iii) contribuir para a protecção e a promoção da saúde dos trabalhadores. Foi construída uma tipologia com cinco grupos principais de políticas, programas e actividades: A (Higiene & Segurança no Trabalho / Melhoria do ambiente físico de trabalho); B (Avaliação de saúde / Vigilância médica / Prestação de cuidados de saúde); C (Prevenção de comportamentos de risco/ Promoção de estilos de vida saudáveis); D (Intervenções a nível organizacional / Melhoria do ambiente psicossocial de trabalho); E (Actividades e programas sociais e de bem-estar). Havia uma lista de mais de 60 actividades possíveis, correspondendo a um índice de realização de 100%. Foi concebido e desenhado, para ser auto-administrado, um questionário sobre Política de Saúde no Local de Trabalho. Foram efectuados dois mailings, e um follow-up telefónico. O trabalho de campo decorreu entre a primavera de 1997 e o verão de 1998. A amostra (n=259) é considerada representativa das duas mil maiores empresas do país. Uma em cada quatro é uma multinacional. A taxa de sindicalização rondava os 30% da população trabalhadora, mas apenas 16% dos respondentes assinalou a existência de representantes dos trabalhadores eleitos para a SH&ST. A hipótese de investigação principal era a de que as empresas com um sistema integrado de gestão da SH&ST seriam também as empresas com um (i) maior número de políticas, programas e actividades de saúde; (ii) maior índice de saúde; (iii) maior índice de realização; e (iv) maior percentagem dos encargos com a SH&ST no total da massa salarial. As actividades de tipo A e B, tradicionalmente associadas à SH&ST, representavam, só por si, mais de 57% do total. Os resultados, correspondentes às respostas da Secção C do questionário, apontam, para (i) a hipervalorização dos exames de medicina do trabalho; e por outro para (ii) o subaproveitamento de um vasto conjunto de actividades (nomeadamente as de tipo D e E), que são correntemente levadas a cabo pelas empresas e que nunca ou raramente são pensadas em termos de protecção e promoção da saúde dos trabalhadores. As actividades e os programas de tipo C (Prevenção de comportamentos de risco/Promoção de estilos de vida saudáveis), ainda eram as menos frequentes entre nós, a seguir aos Programas sociais e de bem-estar (E). É a existência de sistemas de gestão integrados de SH&ST, e não o tamanho da empresa ou outra característica sociodemográfica ou técnico-organizacional, que permite predizer a frequência de políticas de saúde mais activas e mais inovadores. Os três principais motivos ou razões que levam as empresas portuguesas a investir na protecção e promoção da saúde dos seus trabalhadores eram, por ordem de frequência, (i) o absentismo em geral; (ii) a produtividade, qualidade e/ou competitividade, e (iii) a filosofia de gestão ou cultura organizacional. Quanto aos três principais benefícios que são reportados, surge em primeiro lugar (i) a melhoria da saúde dos trabalhadores, seguida da (ii) melhoria do ambiente do ambiente de trabalho e, por fim, (iii) a melhoria da produtividade, qualidade e/ou competitividade.Quanto aos três principais obstáculos que se põem, em geral, ao desenvolvimento das iniciativas de saúde, eles seriam os seguintes, na percepção dos respondentes: (i) a falta de empenho dos trabalhadores; (ii) a falta de tempo; e (iii) os problemas de articulação/ comunicação a nível interno. Por fim, (i) o empenho das estruturas hierárquicas; (ii) a cultura organizacional propícia; e (iii) o sentido de responsabilidade social surgem, destacadamente, como os três principais factores facilitadores do desenvolvimento da política de saúde no trabalho. Tantos estes factores como os obstáculos são de natureza endógena, susceptíveis portanto de controlo por parte dos gestores. Na sua generalidade, os resultados deste trabalho põem em evidência a fraqueza teóricometodológica de grande parte das iniciativas de saúde, realizadas na década de 1990. Muitas delas seriam medidas avulsas, que se inserem na gestão corrente das nossas empresas, e que dificilmente poderão ser tomadas como expressão de uma política de saúde no local de trabalho, (i) definida e assumida pela gestão de topo, (ii) socialmente concertada, (iii) coerente, (iv) baseada na avaliação de necessidades e expectativas de saúde dos trabalhadores, (v) divulgada, conhecida e partilhada por todos, (vi) contingencial, flexível e integrada, e, por fim, (vii) orientada por custos e resultados. Segundo a Declaração do Luxemburgo (1997), a promoção da saúde engloba o esforço conjunto dos empregadores, dos trabalhadores, do Estado e da sociedade civil para melhorar a segurança, a saúde e o bem-estar no trabalho, objectivo isso que pode ser conseguido através da (i) melhoria da organização e das demais condições de trabalho, da (ii) participação efectiva e concreta dos trabalhadores bem como do seu (iii) desenvolvimento pessoal. Abstract Health at work policies: a sociological inquiry into Portuguese corporations Portuguese literature on workplace health policies, programs and activities is still scarce. With this research project the author intends (i) to improve knowledge on the Occupational Health and Safety (shortly thereafter, OSH) management systems and (ii) contribute to the development of health promotion initiatives at a corporate level. Five categories of workplace health initiatives have been identified: (i) Occupational Hygiene and Safety / Improvement of Physical Working Environment (type A programs); (ii) Health Screening, Medical Surveillance and Other Occupational Health Care Provision (type B programs); (iii) Preventing Risk Behaviours / Promoting Healthy Life Styles (type C programs); (iv) Organisational Change / Improvement of Psycho-Social Working Environment (type D programs); and (v) Industrial and Social Welfare (type E programs). A mail questionnaire was sent to the Chief Executive Officer of the 1500 largest Portuguese companies, operating in the primary and secondary sectors (≥ 100 employees) or tertiary sector (≥ 75 employees). Response rate has reached about 20% (259 respondents, representing about 300 companies). Carried out between Spring 1997 and Summer 1998, the fieldwork has encompassed two direct mailings and one phone follow-up. Sample is considered to be representative of the two thousand largest companies. One in four is a multinational. Union membership rate is about 30%, but only 16% has reported the existence of a workers’ health and safety representative. The most frequent workplace health initiatives were those under the traditional scope of the OSH field (type A and B programs) (57% of total) (e.g., Periodical Medical Examinations; Individual Protective Equipment; Assessment of Working Ability). In SMEs (< 250) it was less likely to find out some time-consuming and expensive activities (e.g., Training on OSH knowledge and skills, Improvement of environmental parameters as ventilation, lighting, heating).There were significant differences in SMEs, when compared with the larger ones (≥ 250) concerning type B programs such as Periodical medical examinations, GP consultation, Nursing care, Other medical and non-medical specialities (e.g., psychiatrist, psychologist, ergonomist, physiotherapist, occupational social worker). With regard to type C programs, there were a greater percentage of programs centred on Substance abuse (tobacco, alcohol, and drug) than on Other health risk behaviours. SMEs representatives reported very few prevention- oriented programs in the field of Drug abuse, Nutrition, Physical activity, Off- job accidents, Blood pressure or Weight control. Frequency of type D programs included Training on Human Resources Management, Training on Organisational Behaviour, Total Quality Management, Job Design/Ergonomics, and Workplace rehabilitation. In general, implementation of this type of programs (Organisational Change / Improvement of Psychosocial Working Environment) is not largely driven by health considerations. Concerning Industrial and Social Welfare (Type E programs), the larger employers are in a better position than SMEs to offer to their employees a large spectrum of health resources and facilities (e.g., Restaurant, Canteen, Resting room, Transport, Infra-structures for physical activity, Surgery, Complementary social protection, Support to recreational and cultural activities, Magazine or newsletter, Intranet). Other workplace health promotion programs like Training on Stress Management, Employee Assistance Programs, or Self-help groups are uncommon in the Portuguese worksites. The existence of integrated OSH management systems, not the company size, is the main variable explaining the implementation of more active and innovative workplace health policies in Portugal. The three main prompting factors reported by employers for health protection and promotion initiatives are: (i) Employee absenteeism; (ii) Productivity, quality and/or competitiveness; and (iii) Corporate culture/management philosophy. On the other hand, (i) Improved staff’s health, (ii) Improved working environment and (iii) Improved productivity, quality and/or competitiveness were the three main benefits reported by companies’ representatives, as a result of successful implementation of workplace health initiatives. (i) Lack of staff commitment; (ii) Lack of time; and (iii) Problems of co-operation and communication within company or establishment (iii) are perceived to be the main barriers companies must cope with. Asked about the main facilitating factors, these companies have pointed out the following ones: (i) Top management commitment; (ii) Corporate culture; and (iii) Sense of social responsibility. This sociological research report shows the methodological weaknesses of workplace health initiatives, carried out by Portuguese companies during the last ‘90s. In many cases, these programs and actions were not part of a corporate health strategy and policy, (i) based on the assessment of workers’ health needs and expectancies, (ii) advocated by the employer or the chief executive officer, (ii) planned and implemented with the staff consultation and participation or (iv) evaluated according to a cost-benefit analysis. In short, corporate health policy and action were still rather based on more traditional OSH approaches and should be reoriented towards Workplace Health Promotion (WHP) approach. According to the Luxembourg Declaration of Workplace Health Promotion in the European Union (1997), WHP is “a combination of: (i) improving the work organisation and environment; (ii) promoting active participation; (iii) encouraging personal development”.Résumée Politique(s) de santé au travail: une enquête sociologique aux entreprises portugaises Au Portugal on ne sait presque rien des politiques de santé au travail, adoptés par les entreprises. Avec ce projet de recherche, on veut (i) améliorer la connaissance sur les systèmes de gestion de la santé et de la sécurité au travail et, au même temps, (ii) contribuer au développement de la promotion de la santé des travailleurs. Une typologie a été usée pour identifier les politiques, programmes et actions de santé au travail: A. Amélioration des conditions de travail / Sécurité au travail; B. Médecine du travail /Santé au travail; C. Prévention des comportements de risque / Promotion de styles de vie sains; D. Interventions organisationnelles / Amélioration des facteurs psychosociaux au travail; E. Gestion de personnel et bien-être social. Un questionnaire postal a été envoyé au représentant maximum des grandes entreprises portugaises, industrielles (≥ 100 employés) ou des services (≥ 75 employés). Le taux de réponse a été environ 20% (259 répondants, concernant trois centaines d’entreprises et d’établissements). La recherche de champ, conduite du printemps 1997 à l’été 1998, a compris deux enquêtes postales et un follow-up téléphonique. L´échantillon est représentatif de la population des deux miles plus grandes entreprises. Un quart sont des multinationales. Le taux de syndicalisation est d’environ 30%. Toutefois, il y a seulement 16% de lieux de travail avec des représentants du personnel pour la santé et sécurité au travail. Les initiatives de santé au travail les plus communes sont celles concernant le domaine plus traditionnel (types A et B) (57% du total): par exemple, les examens de médecine du travail, l’équipement de protection individuelle, les tests d’aptitude au travail. En ce qui concerne les programmes de type C, les plus fréquents sont le contrôle et la prévention des addictions (tabac, alcool, drogue). Les interventions dans le domaine de du système technique et organisationnelle du travail peuvent comprendre les courses de formation en gestion de ressources humaines ou en psychosociologie des organisations, l’ergonomie, le travail posté ou la gestion de la qualité totale. En général, la protection et la promotion de la santé des travailleurs ne sont pas prises en considération dans l’implémentation des initiatives de type D. Il y a des différences quand on compare les grandes entreprises et les moyennes en matière de politique de gestion du personnel e du bien-être (programmes de type E, y compris l’allocation de ressources humaines ou logistiques comme, par exemple, restaurant, journal d’entreprise, transports, installations et équipements sportifs). D’autres activités de promotion de la santé au travail comme la formation en gestion du stress, les programmes d’ assistance aux employés, ou les groupes de soutien et d’auto-aide sont encore très peu fréquents dans les entreprises portugaises. C’est le système intégré de gestion de la santé et de la sécurité au travail, et non pas la taille de l’entreprise, qui aide à prédire l’existence de politiques actives et innovatrices dans ce domaine. Les trois facteurs principaux qui encouragent les actions de santé (prompting factors, en anglais) sont (i) l’absentéisme (y compris la maladie), (ii) les problèmes liés à la productivité, qualité et/ou la compétitivité, et aussi (iii) la culture de l’entreprise/philosophie de gestion. Du coté des bénéfices, on a obtenu surtout l’amélioration (i) de la santé du personnel, (ii) des conditions de travail, et (iii) de la productivité, qualité et/ou compétitivité.Les facteurs qui facilitent les actions de santé au travail sont (i) l’engagement de la direction, (ii) la culture de l’entreprise, et (iii) le sens de responsabilité sociale. Par contre, les obstacles à surmonter, selon les organisations qui ont répondu au questionnaire, seraient surtout (i) le manque d’engagement des travailleurs et de leur représentants, (ii) le temps insuffisant, et (iii) les problèmes de articulation/communication au niveau interne de l’entreprise/établissement. Ce travail de recherche sociologique montre la faiblesse méthodologique des services et activités de santé et sécurité au travail, mis en place par les entreprises portugaises dans les années de 1990, à la suite des accords de concertation sociale de 1991. Dans beaucoup de cas, (i) ces politiques de santé ne font pas partie encore d’un système intégré de gestion, (ii) il n’a pas d’évaluation des besoins et des expectatives des travailleurs, (iii) c’est très bas ou inexistant le niveau de participation du personnel, (iv) on ne fait pas d’analyse coût-bénéfice. On peut conclure que les politiques de santé au travail sont plus proches de la médecine du travail et de la sécurité au travail que de la promotion de la santé des travailleurs. Selon la Déclaration du Luxembourg sur la Promotion de la Santé au Lieu de Travail dans la Communauté Européenne (1997), celle-ci « comprend toutes les mesures des employeurs, des employés et de la société pour améliorer l'état de santé et le bien être des travailleurs » e « ceci peut être obtenu par la concentration des efforts dans les domaines suivants: (i) amélioration de l'organisation du travail et des conditions de travail ; (ii) promotion d'une participation active des collaborateurs ; (iii) renforcement des compétences personnelles ».

Determinants of the use of health care services: multilevel analysis in the Metropolitan Region of Sao Paulo

OBJECTIVE To evaluate the individual and contextual determinants of the use of health care services in the metropolitan region of Sao Paulo.METHODS Data from the Sao Paulo Megacity study – the Brazilian version of the World Mental Health Survey multicenter study – were used. A total of 3,588 adults living in 69 neighborhoods in the metropolitan region of Sao Paulo, SP, Southeastern Brazil, including 38 municipalities and 31 neighboring districts, were selected using multistratified sampling of the non-institutionalized population. Multilevel Bayesian logistic models were adjusted to identify the individual and contextual determinants of the use of health care services in the past 12 months and presence of a regular physician for routine care.RESULTS The contextual characteristics of the place of residence (income inequality, violence, and median income) showed no significant correlation (p > 0.05) with the use of health care services or with the presence of a regular physician for routine care. The only exception was the negative correlation between living in areas with high income inequality and presence of a regular physician (OR: 0.77; 95%CI 0.60;0.99) after controlling for individual characteristics. The study revealed a strong and consistent correlation between individual characteristics (mainly education and possession of health insurance), use of health care services, and presence of a regular physician. Presence of chronic and mental illnesses was strongly correlated with the use of health care services in the past year (regardless of the individual characteristics) but not with the presence of a regular physician.CONCLUSIONS Individual characteristics including higher education and possession of health insurance were important determinants of the use of health care services in the metropolitan area of Sao Paulo. A better understanding of these determinants is essential for the development of public policies that promote equitable use of health care services.

Analysis and recognition of similar environmental sounds

Dissertação apresentada na Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa para obtenção do grau de Mestre em Engenharia Informática

Environmental policies in an international mixed duopoly

The purpose of this paper is to study the effects of environmental and trade policies in an international mixed duopoly serving two markets. We suppose that the firm in the home country is a welfare-maximizing public firm, while the firm in the foreign country is its own profit-maximizing private firm. We find that the environmental tax can be a strategic instrument for the home government to distribute production from the foreign private firm to the home public firm. An additional effect of the home environmental tax is the reduction of the foreign private firm's output for local consumption, thereby expanding the foreign market for the home public firm.

Economies of scale and scope in the provision of diagnostic techniques and therapeutic services in Portuguese hospitals

This paper analyses the provision of auxiliary clinical services that are typically carried out within the hospital. We estimate a exible cost function for the three most important (cost- wise) diagnostic techniques and therapeutic services in Portuguese hospitals: Clinical Pathology, Medical Imaging and Physical Medicine and Rehabilitation. Our objective in carrying out this estimation is the evaluation of economies of scale and scope in the provision of these services. For all services, we nd evidence of ray economies of scale and some evidence of economies of scope. These results have important policy implications and can be related to the ongoing discussion of where and how should hospitals provide these services.

Determinação do teor de compostos aromáticos policíclicos de óleos minerais isolantes para transformadores

Mestrado em Engenharia Química - Ramo Optimização Energética na Indústria Química

An environmental atlas of Albania

Dissertation submitted in partial fulfilment of the requirements for the Degree of Master of Science in Geospatial Technologies

Environmental and international tariffs in a mixed duopoly

In this paper, we study the effects of environmental and trade policies in an international mixed duopoly serving two markets, in which the public firm maximizes the sum of consumer surplus and its profit. We also analyse the effects of privatization. The model has two stages. In the first stage, governments choose environmental taxes and import tariffs, simultaneously. Then, the firms engage in a Cournot competition, choosing output levels for the domestic market and to export. We compare the results obtained in the three different ways of moving on the decision make of the firms.

Designing market-based instruments for biodiversity conservation: learning with the Australian experience and evaluating Portugal's potential

Dissertação apresentada na Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa para a obtenção do grau de Mestre em Engenharia do Ambiente, perfil Gestão de Sistemas Ambientais

Gestão de resíduos produzidos num sistema de drenagem e tratamento de águas residuais

O presente trabalho centra-se na gestão de resíduos produzidos no sistema de drenagem e tratamento de águas residuais do município de Vila Nova de Gaia. A entidade onde decorreu o trabalho é uma empresa responsável pela distribuição de água e pela drenagem e tratamento de águas residuais. A empresa está certificada pela norma NP EN ISO 14001, desde 2001, sendo então um dos objectivos o enquadramento da gestão dos resíduos em estudo na referida norma, acompanhando os requisitos da mesma com vista ao seu total cumprimento. Outros dos objectivos foi estudar qual a opção de tratamento mais adequada a aplicar ao resíduo no seu local de armazenamento temporário com vista a minorar os seus impactes ambientais. De acordo com a caracterização analítica do resíduo e com os aspetos legais aplicáveis, foram também analisados os destinos finais possíveis e ambientalmente adequados ao resíduo. A medida proposta para a minimização de impactes no local de armazenamento temporário do resíduo foi a estabilização com cal nos leitos de secagem, disponíveis numa antiga ETAR de loteamento. O doseamento de cal a aplicar ao resíduo será de 10 kg de cal apagada comercial (Ca (OH)2) por uma tonelada de resíduo fresco com um período mínimo de secagem de 2 meses. Outra das medidas de minimização de impactes selecionada foi a implantação de uma cortina arbórea ao redor da instalação. Sendo o resíduo em estudo muito heterogéneo, constituído principalmente por areias, terras e gradados, a valorização foi equacionada mas não foram encontrados alternativas viáveis. O destino final considerado como mais adequado tendo em conta todas as características do resíduo e eluato, analisadas de acordo com o previsto no Decreto-Lei n.º 183/2009 de 10 de Agosto, foi o aterro para resíduos não perigosos. Foi também objecto do estudo a identificação e análise de todos os aspectos ambientais relacionados com a gestão de resíduos e a avaliação da sua significância. Dos aspectos ambientais identificados como significativos, destacam-se aqueles que ocorrem presentemente, os resíduos armazenados (gradados/limpeza de redes), e os que podem ocorrer em situações de emergência, fuga/derrame de óleos/combustíveis e cheiros/odores. De forma a minimizar os aspectos ambientais identificados, e de acordo com a norma NP EN ISO 14001, foram propostas ações que constam de um programa de gestão elaborado para este trabalho, onde se definem os objectivos, metas e prazos. As principais medidas propostas no programa de gestão foram: Estabilização com cal (inicial e reforço se necessário); melhoria do espaço envolvente; análise de questões de saúde ocupacional/segurança; adjudicação de prestação de serviços da recolha por operador licenciado; implantação da cortina arbórea; registo no SIRAPA; criação de planos de emergência ambiental e de segurança.